A nurse enters a client's room and finds the client experiencing a seizure on the floor. Which of the following actions should the nurse take?

Place a pillow under the client's head.

Gently restrain the client's arms.

Administer a muscle relaxant.

Insert a tongue blade.

Answer and Explanation

The Correct Answer is A

A. Place a pillow under the client's head. Placing a pillow under the client's head is appropriate as it helps protect the client's head from injury during the seizure. Providing cushioning can reduce the risk of head trauma, which is a common concern during seizures.
B. Gently restrain the client's arms. Gently restraining the client's arms is not recommended during a seizure, as it can lead to injury. Restraining movements can also increase the risk of injury to both the client and the caregiver. Instead, the nurse should allow the seizure to progress without interference.
C. Administer a muscle relaxant. Administering a muscle relaxant is not appropriate during a seizure. The nurse should not medicate the client until the seizure has stopped and the healthcare provider has assessed the situation. Immediate management focuses on safety rather than medication.
D. Insert a tongue blade. Inserting a tongue blade or any object into the client's mouth is dangerous and not recommended. This can cause oral injury, broken teeth, or airway obstruction. The nurse should ensure the area is clear of hazards and allow the seizure to occur without attempting to prevent movements.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. "Sit on the edge of the bed while I tap your knee." The patellar reflex, also known as the knee-jerk reflex, is tested by tapping the patellar tendon while the client’s leg dangles. This does not assess the Babinski reflex, which involves stroking the sole of the foot.
B. "Lie down and I will stroke the bottom of your foot." The Babinski reflex is tested by stroking the lateral aspect of the sole from heel to toe. A normal response in adults is toe flexion, while dorsiflexion of the great toe with fanning of the others is abnormal and indicates neurological dysfunction.
C. "Place your foot in my hand and I will tap the back of your heel." This describes testing for the Achilles tendon reflex, which assesses the function of the S1 spinal nerve. The Babinski reflex requires a stroking motion along the foot’s sole rather than tapping the heel.
D. "Relax your arm across your chest and I will test your elbow extension." This describes testing the triceps reflex, which assesses the function of the C6-C7 nerve roots. The Babinski reflex is specific to neurological assessment of the lower extremities.

A. "You should avoid exercising for the next 6 weeks." B. "You should avoid putting a pillow between your legs when in bed." C. "You should avoid lying on your right side." D. "You should avoid crossing your legs for 3 months."

Correct Answer is D

Explanation

A. "You should avoid exercising for the next 6 weeks." Exercise is encouraged after a total hip arthroplasty to promote circulation, prevent complications such as deep vein thrombosis, and strengthen the muscles supporting the hip joint. However, high-impact activities should be avoided until cleared by the healthcare provider.
B. "You should avoid putting a pillow between your legs when in bed." Placing a pillow between the legs, especially while sleeping, helps maintain proper hip alignment and prevents excessive internal rotation or adduction, reducing the risk of dislocation.
C. "You should avoid lying on your right side." Lying on the operative side is not necessarily contraindicated, but it should be done with caution and with proper support. Clients are usually advised to lie on their non-operative side with a pillow between their legs for alignment.
D. "You should avoid crossing your legs for 3 months." Crossing the legs can cause hip adduction and internal rotation, increasing the risk of dislocation of the prosthetic joint. Clients are typically instructed to avoid crossing their legs for at least 3 months or until cleared by their provider.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse enters a client's room and finds the client experiencing a seizure on the floor. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to test a client's plantar Babinski reflex. Which of the following instructions should the nurse give to prepare the client for this test?

Correct Answer is B

Explanation

A nurse is reinforcing discharge teaching with a client who had a right total hip arthroplasty. Which of the following instructions should the nurse include?

Correct Answer is D

Explanation

A nurse is assisting with the care of a client who has pneumonia. Exhibits For each potential nursing action, click to specify if the potential action is anticipated or contraindicated for the client.

Exhibits Which of the following findings requires further action by the nurse? Select all that apply.

A nurse is caring for a client who has peptic ulcer disease and is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take prior to the procedure?

A nurse is reinforcing teaching with a parent of a child who has asthma about the administration of montelukast. Which of the following statements by the parent indicates an understanding of the teaching?

A nurse is caring for a client in an outpatient clinic. Exhibits Complete the following sentence by using the lists of options. The client is at highest risk for developing dropdownevidenced by the client'sdropdown

A nurse in an acute care setting is assisting in collecting client information to include in a referral for a physical therapist. Which of the following information should the nurse plan to include?

A nurse enters a client's room and finds the client experiencing a seizure on the floor. Which of the following actions should the nurse take?

A nurse is caring for a child who has terminal cancer. Which of the following responses by the child's school-age brother should the nurse expect?